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HomeMy WebLinkAboutBLD2008-00036 IIR UILDING PERMIT APPLICAIN BRDOw00036 Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD08-00036 Received Date: 1/30/2008 SITE ADDRESS: 240 MUNN RD QUILCENE, 98376 OWNER: THOMAS F KUYKENDALL PHONE: 360-765-0330 NANCI KUYKENDALL 240 MUNN RD QUILCENE WA 983768535 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 802261010 Section: 26 Township: 28 N Range: 02 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI THIS IS NOT A BLD PERMIT - TITLE ELIMINATION ONLY RECORD - NOT A LIFE SAFETY REVIEW - SERIAL #54844 TYPE OF WORK T.E SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION MAIN: CODE EDITION: 1976 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid Bv: Date: Receipt: Approved/Date Total: cns, 6, JEFFERSO•OUP�TY �g r� DEPARTMENT OF COMMUNITY DEVELOPMENT _ '' e 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax QSO,O www.co.jefferson.wa.us/commdevelopment JAN 3 O 2008 Master Permit Application MLA: NO Y", L k Project Descriptioni (include separate sheets s necessary): 1 l i T ,-c ( r tea►` vl,,, ) •L'M u���l I R I m Ct s1 tJ -fret _'I r Y° L 41)41_4_ Tax Parcel Property Number: ',)Q >( �) / () Size: /0 . �� (. - 'square feet) Site Address and/or Directions to Property: 4/6 /?o 1 rt ,,-:, Ci j atA 1 e.-ed-'-�_ Zd9- 6153.7-6 Property Owner(s)of Record: 7c1Mc <., e Nabt c., i!,, k e.,-. cl (/ Telephone: -3(..-,0 - 74-c.? c.3 3[3 Fax: 34,e ._ 7 - .26' , email: e:inevvt4 s k 3 (9 Pepe-.<<')7.7 Mailing Address: C.,?Z/1I yy.,.,,.,,.r A,n ek.C4 0C)1 /e-to n..r L J 4 ' g .7 C-,. Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies ❑Building 0 Variance(Minor, Major or Reasonable Ergonomic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or C]"'* ❑ Single Family ❑ Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home ❑ Modular 0 Special Use(Essential Public Facilities)** ❑ Commercial* ❑ Boundary Line Adjustment ❑ Change of Use ❑Short Plat** ❑ Address 0 Road Approach ❑ Binding Site Plan** ❑ Home Business ❑ Cottagelndustry ❑ Long Plat** ❑ Propane ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑Sign ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest PSadices Act/Release of Six-Year Moratorium ❑Tree Vegetaion Request _ *May require a Pre—Application Conference **Requires a Pre-Application Confei�nce, Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE C am— ,G��/lam, /-' / Date: /"/"1/,y By signing this application form,the owfier/agent attests that the information provided herein,and in any attachments, true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required later inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the applicatin thatat he or she wants prior noti Signature: ; : ri --?.— Date: r/tc) e'r- The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable r sponsibility fo adherin to and complying with the ESA. The Applicant has read this discllaii er a signs and dates it below. Signature: _,1 Date: ems/..V e . G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc i-- • • - ' * "' Z. tr.:A. :*. t1 -N% ' - -\ I• ••-• 1. • •.., .''' elk... -\-1, ,.. lc:sr": -... - - -.....- --) • ..- i . . iftg"• ., sot, 0 r.4• 1.0 1. tirit % -- 1 .- ,,. ..... i jilos,4 ?CZ,r- . /// — ..„.—.... ( Rs 're " . • , // . t 1... , .. • P-C‘ , , . . 1 7<----- c ree,k • . • 1 - • _____..............madi • p------ ... 1 .,. ..2'. AIMIIIIIMIft -. , kJ.% - -----, ,.., 1 - A4 44 • . . . . . . i A.- • • RETURN ADDRESS CLS Escrow, Inc. #10808 PO Box 141037 Spokane, WA 99214 WASHINGTON STATE DEPARTMENT OF Manufactured Home 'L AS CH CK ONE dm LICENSING Application TITLE ELIMINATION ❑TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ❑REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) $04611 1976 KIT 64 X 14 S4844 © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE REAL PROPERTY TAX PARCEL NUMBER AFFIXED ❑ REMOVED 802261010 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION Sec 26 Twn 28N Rng 2 W S1/2 S1/2 NW1/4 NE1/4 0 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER THOMAS F.KUYKENDALL NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER NANCI B.KUYKENDALL ADDRESS CITY STATE ZIP CODE 240 MUNN ROAD QUILCENE WA 98376 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER CLS MORTGAGE,INC. ITS SUCCESSORS AND/OR ASSIGNS NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 12904 E.NORA AVE. SPOKANE VALLEY WA 99216 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: �/�' Signature of Registered Owner and Title, IF APPLICABLE Y� " /`r // ,///f .- Signature of Additional Registered Owner and Title,IF APPLICABLE kj/,Irthet)l etA,V (� G�-�. NOTARY SEAL OR STAMP YY NOTARIZATION/CERTIFICATION FOR REGIST REDrb,WNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. 0 BUILDING PERMIT OFFICE CERTIFICATION I certify that: ft the manufactured home has been affixed to the real property as described. El a building permit has been issued for this purpose and the attachment will be inspected upon completion. 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